Form ID-01

Ver 8

Application number: LOB / Agent Code Channel Code Advisor/FSC Name

OL00133810 00066918 DM E Business Company.. FSM/FSC Code: LIM/CSR Code: NA Bank A/C: NA

App Received Date: 2011-09-26

00DM NBNK Bank Branch CAFOS Code Opportunity ID:

0WEB Source

IMPORTANT GUIDELINES: This online process is applicable only to Resident Indians and the payment would be accepted in INR only The Life Assured, Proposer and payer shall be the same person and cannot be different. The policy will be issued on the basis of the Date of Birth provided on the application form. Insurance is a contract of utmost good faith requiring of the Proposer / Life Assured not only to disclose all material facts but also not to suppress any material facts in response to the questions in the proposal form. Kindly note that any non-disclosure of information or misstatement in the form may lead to decline of proposal/repudiation of claim arising out of this policy by the company. Proposer should use only his/her credit card OR internet banking account for payment of premium. Use of credit card OR internet banking account of persons other than the Proposers will lead to decline of proposal/payment. A. PERSONAL DETAILS Were you assisted by an authorized representative? :No Please fill the details as provided by the authorized representative, for tracking this application Please enter Representative's identification code: 00066918 1. Full name: This is how your name will appear on the policy certificate. Please leave a space between each part of the name. First Name Surname Rajesh Sharma Father / Husbands Name: Ramesh Sharma 2. Date of Birth: 3. Age Proof: 4/09/1974 LIC Policy - standard proof (The policy would be issued basis the disclosure made regarding Date of Birth. Company reserves the right to call for the age proof any time after the policy issuance ) 4. Gender: 5. Marital Status: Male Married 7. Education: Graduate 6. Nationality: Indian 8. Occupation: Salaried 9. Organization: Public Ltd 10. Designation: Project Manager 11. Your Annual Income: 1050000 No 12. Are you a Politically Exposed Person (PEP): 13. Communication Address: Line1: Line2: Land Mark: State: Mobile: Email ID: Flat No 366, Vijay Vilas, Off Ghodbunder Road, Behind Muchhala College Maharashtra 9920245811 rajsh.sharma@gmail.com

City: Landline:

Thane 25970301

Pin Code: Country:

400607 India

14. Permanent address (if different than above) Line1: Line2: Land Mark: State: Mobile: City: Landline: Pin Code: Country:

Email ID: 15. Do you have any existing life cover and/or are you simultaneously applying for life cover with ICICI Prudential Life Insurance Co. Ltd. No If Yes please provide the following details Policy number Basic Sum Assured Base Plan / Rider Decision*

Total Amount

* Terms of acceptance (decision) Standard, Revised premium, Postponed, declined, offered with modified terms. 16. Do you have any existing life insurance cover with other companies? Yes If Yes please provide the following details Name Of Company Basic Sum Assured Base Plan / Rider Decision* LIC India 750000 Standard

* Terms of acceptance (decision) Standard, Revised premium, Postponed, declined, offered with modified terms.

B. NOMINEE DETAILS 1. First Name Shikha 2. Date of Birth: 15/9/1979 4. Relationship to Life Assured: Spouse 5. Address (to be filled if different from Life Assured's communication Address) Line1: Line2: Land Mark: State: Mobile: Email ID: Flat No 366, Vijay Vilas, Off Ghodbunder Road, Behind Muchhala College Maharashtra 9920245811 rajsh.sharma@gmail.com Surname Sharma 3. Gender: Female

City: Landline:

Thane 25970301

Pin Code: Country:

400607 India

C. APPOINTEE DETAILS (Only if the nominee is a minor) Surname 1.First Name 2.Date of Birth: 4.Relationship to Life Assured: D. HEALTH DECLARATION Note: Please enter correct details on the medical questionnaire below to enable smoother processing of claims. 1. a) Height b) Weight 5'8'' 84 kg No No 3.Gender:

c) Have you had any loss or gain of weight of 10 Kg or more in the last 6 months? 2. Do you consume or have you ever consumed Tobacco or any nicotine products in any form. If Yes please provide the following details Substance consumed Response If yesConsumed as If YesFrequency / day

If YesDuration(No of years)

Tobacco

NO

NM

NM

NM

Please provide the following details if you consume or have ever consumed the following: Response If yesConsumed as If YesFrequency / If YesDuration(No Substance Week of years) consumed

Alcohol

NO

NM

NM

NM

Narcotics

NO No

3. Life style details of the life to be assured. Is your occupation associated with any specific hazard or do you take part in hazardous activities or have hobbies that could be dangerous in any way or do you intend to travel, live or work outside India for more than six months? 4. Family details of the life to be assured. Before age 50, have any of your natural parents or siblings died or suffered from cancer, heart disease, stroke, high blood pressure, diabetes, kidney diseases, polycystic kidney or any hereditary disease ? 5. Health details of the life to be assured. a. Are you currently under medical treatment or being advised to take medical treatment and /or suffering from any physical or mental impairment or congenital abnormality? b. In the recent ten years, have you undergone or been advised to consult a specialist doctor or undergo any tests or investigations such as X-ray, scanning (ultrasound, CT,MRI,PET), biopsy, Pap smear, mammogram,angiogram, electrocardiogram (ECG), blood or urine test or been hospitalized for observation, treatment or surgery? c. Have you ever undergone any surgical procedure(s) including - angioplasty, bypass surgery, brain surgery, heart surgery,organ transplant, excision of tumour or growth or been admitted to hospital for two days or more or received continuous medical treatment for five days or more (for reasons other than flu, common cold, throat infection, sprains, fever)? d. Have you ever suffered or been diagnosed with or been treated for any of the following: i)Epilepsy, stroke, transient ischemic attack, double vision, paralysis, weakness of limb, persistent headache, nervous breakdown, depression or any other nervous/mental disorders? ii)Diabetes, high blood sugar, thyroid or other glands disorders or any other endocrine disorders? iii)Anaemia, haemophilia, raised cholesterol, high blood pressure or other cardiovascular conditions- e.g.heart attack, heart murmur, heart valve disease or disorders, breathlessness, palpitations, chest discomfort or pain, disease of or any other disorder of the heart, blood or blood vessels? iv)Asthma, persistent cough, coughing with blood, pneumonia, tuberculosis, breathing discomfort or anyother lung or respiratory system disorders? v)Chronic Gastritis, stomach or duodenal ulcer, blood in stools, fistula, piles or any other stomach,intestines or bowel disorders?

No

No No No

No No No No No

vi) Jaundice, hepatitis B carrier or any other form of hepatitis, liver disorder or gall bladder disorder? vii) Gout, arthritis, pain or deformity or disorders of the muscles, spine, limbs or joints or severe injury? viii) Blood, protein or sugar in urine, kidney stones, infection or any other disorders of the kidney, bladderor genital organs? ix) Cancer, tumour, cyst or growth of any kind? e. Were you or your spouse ever tested for hepatitis B or C, HIV/AIDS or any other sexually transmitted disease? f. Have you ever suffered or suffering from any other ailment / disorder which is specifically not mentioned above 6. The Following Question Needs to be Answered only if the Life to be Assured is a Female: a. Have you ever suffered /are suffering from or have ever undergone any investigation or treatment or received medical advice or consulted a physician for any gynecological complications such as miscarriage, medical termination of pregnancy, disorder of cervix, uterus, ovary, (ies) , breast(s), breast lump /cyst, fibrocystic disease etc b. Are you pregnant at present? If yes, duration in weeks c. Maiden Name (for female lives only) If your answer to any of the questions from Q.No. 2 to 6 is Yes, please provide details below: Question number Details if marked 'Yes'

No No No No No No

NA NA NA NA

E.PARTICULARS

Age Gender Term Sum Assured Accidental Death Benefit Tobacco usage Premium Frequency

37 Male 25 5000000 5000000 No Annual

Premium Service Tax, as applicable Cesses, as applicable Total Amount payable Product Name: iProtect Option II Product Code: T25

11000 1100 33 12133 Product UIN: 105L105V01

i) The benefit amount for Accidental Death Benefit under iProtect Option II will be equal to Sum Assured or Rs. 50,00,000, whichever is lower. ii) Accidental Death Benefit is an inbuilt feature of iProtect Option II and it is not a rider. This amount cannot be increased or decreased at the option of the Policyholder. iii) The maximum benefit that can be paid under Accidental Death Benefit in respect of all policies taken by you under iProtect Option II cannot exceed Rs. 50,00,000 iv) In case you are an existing iProtect Option II policyholder, we suggest that you: i) select a Sum Assured such that the total Accidental Death Benefit under all your iProtect Option II policies does not exceed Rs. 50,00,000 or ii) opt for the iProtect Option I, which does not have Accidental Death Benefit In case the total Accidental Death Benefit under all iProtect Option II policies exceeds Rs. 50,00,000, the Company shall cancel the policies, starting from the most recently issued policy, such that the total Accidental Death Benefit under all iProtect Option II is less than or equal to Rs. 50,00,000. In case any policy is cancelled, the Company shall refund the premiums paid by you without any interest. The Company will cancel the entire policy and will not cancel any policy in part. Declaration & Authorization : 1. The premium calculated above is based on the data provided by you in the application form. 2. The Company may call upon you to submit the standard age proof, Income proof and other KYC documents 3. Complete disclosures about your existing policies, health details and other material details should be made to the Company failing which the Company may declare the policy null and void ab initio, subject to the provisions of Section 45 of the Insurance Act, 1938. 4. The above information must be read in conjunction with the sales brochure and policy document. 5. The policy does not acquire any surrender value.

6. There are no maturity benefits under the plan 7. ICICI Pru iProtect Option II is only the name of the policy and does not in any way indicate the quality of the policy. 8. Tax Benefits would be available as per the prevailing Income Tax laws. 9. Service tax and education cess would be levied as per applicable tax laws. 10. For any further clarifications, please feel free to contact us or e-mail us on lifeline@iciciprulife.com 11. Insurance is the subject matter of solicitation.

Important Terms and Conditions:

I declare that I have answered the questions in the proposal form of ICICI Prudential Life Insurance Company Limited, (hereinafter referred to as the Company) and have fully understood the nature of the questions including health related questions and the importance of disclosing all material information while answering such questions. I further declare that the answers given by me to all the questions in the proposal form of the Company as to the state of health and habits of the life to be assured, that is mine, are true and complete in every respect and that I also understand that any mis-statement or suppression of material information or where the Company is not notified of the change in health the Company has the right to repudiate the claim under this policy. I undertake to notify the Company of any change in the state of health of the life to be assured, that is mine, or as to my occupation subsequent to the signing of this proposal and before the acceptance of the risk by the Company. I also understand that in case of any mis-statement or suppression of material information the Company has the right to decline the application/repudiate the claim under this policy in accordance with Section 45 of the Insurance Act. I also understand that the terms and conditions including the premium and the benefits payable under the policy are subject to taxes/duties/charges in accordance to the applicable laws. I confirm that all premiums will be paid from bonafide sources. I further declare that the premium is being paid from my credit card/internet bank account. The Claimant shall be required to produce the valid age proof of the policyholder, as acceptable to the Company in the event of claim. The Company reserves the right to accept, decline or offer alternate terms on my proposal for life insurance. In order to enable the Company to assess the risk under this proposal and any time thereafter, I hereby, authorize the past and present employers(s)/ business associates/ medical practitioner/ hospital / any life and non-life insurance Company/or organization or Life Insurance Associations medical register to release to the Company and the Company to release to any life and non-life insurance Company/or Life Insurance Association or medical register, such details and provide the records of employment/business or other details as may be considered relevant. This proposal form shall be a part of the life insurance policy contract, in case of its acceptance by the Company Section 41: In accordance to the Section 41 of the Insurance Act, 1938, no person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer. Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be acceptance of a rebate of premium within the meaning of this sub section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by the insurer. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees Section 45 - Policy not to be called in question on ground of mis-statement after two years.No policy of life insurance effected before the commencement of this Act shall after the expiry of two years from the date of commencement of this Act and no policy of life insurance effected after the coming into force of this Act shall after the expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy-holder and that the policy-holder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose. Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal. I declare that I am submitting a proposal for life insurance to ICICI Prudential Life Insurance Company Ltd. (Company) through the Companys website, after satisfying myself of the truthfulness of the statements made by me herein and of the need to disclose all material facts, as required under Section 45 of the Insurance Act, 1938. I understand and I agree that by submitting this proposal through the Company website, I will be bound by such statements / non-disclosure of material facts in the same manner and to the same extent as if I have signed and submitted a written proposal for insurance to the Company. I Rajesh , having received the information with respect to the above, have understood the

statement before entering into the contract